menopause and hormones

Question 1

average age of menopause

Answer 1

51.5

Question 2

definition of menopause

Answer 2

1 year of amenorrhea

Question 3

definition of POI

Answer 3

menopause <40

Question 4

etiology of POI

Answer 4

• genetic: turners, fragile X, mosaicism XO/XX
• iatrogenic - chemo, rad, surg
• autoimmune
• infectious
• metabolic - galactossemia
• most often idiopathic

Question 5

perimenopause definition

Answer 5

4-5 years of hormone fluctations prior to menopause + 1 year after FMP

Question 6

What are inhibins

Answer 6

excreted by ovary, inhibit hypothalamic secretion of GnRH

Question 7

HPO axis

Answer 7

hypoT secretes GnRH

pituitary secretes LH and FSH

ovary secretes E + P, neg feedback to both above

Question 8

types of estrogens

Answer 8

estradiol (E2) - from follicle

estrone (E1) - from metabolism of estradiol and peripherally made from adrenal precursors

Estriol (E3)

Question 9

measure of ovarian reserve

Answer 9

AMH

Question 10

estrogen receptor types

Answer 10

alpha - mostly in reproductive organs & breast, also in liver, bone adipose, brain

beta - more in colon, vasc, lung, bladder, brain

both in ovary, CNS, cardiovasc

estradiol binds both

Question 11

SERMS

Answer 11

bind only alpha or beta estrogen receptors

eg tamoxifen, clomiphene

Question 12

physiology in late reproductive phase

Answer 12

• menstrual cycle changes
• FSH + E2 variable
• AMH low
• inhibin B low
• day 3 FSH > 10
• cycles shorten as FSH recruits follicles earlier
• symptoms from FSH + temp higher E (sore breast, anovulation, bloating, irritability, menorrhagia, fibroid growth, nausea)

Question 13

peri-menopause symptoms + physiology

Answer 13

• erratic cycles, then stop
• heavy bleed or post-menopausal: workup
• more anovulation
• E and P lower
• E esp lower 6 months before LMP
• still use contraception
• testosterone same or lower
• SHBG decreases
• adrenal hormones decrease

Question 14

post-meopausal physiology

Answer 14

• high FSH + LH (eventually stabilizes)
• loss neg feedback, E low
• estrone dominant E
• no ovulation
• no progesterone

Question 15

signs and symptoms of hypoE

Answer 15

hot flashes + night sweats
vaginal - dry, dysparuenia, pruritis
sleep
urinary freq, urgency, stress
sex dysfunction
depression, anxiety, irritability
memory loss
joint pain
weight gain
headaches

Question 16

physiology of hot flashes

Answer 16

narrowed thermoreg centre in ant hypothalamus

body temp rises, vaso dilate to cool

Question 17

worsens hot flashes

Answer 17

smoking, obesity, alcohol, sedentary, genetics, low SES

Question 18

associated conditions w hot flashes

Answer 18

memory, depression, sleep issues

if early onset + freq: cardiovasc risk (increased endothelial reactivity)

Question 19

differential dx for hot flashes

Answer 19

hyperthyroidism
infection, tb
malignancies - blood, pheochromocytoma, insulinoma
meds: nitrates, tamoxifen, aromatase inhib

don’t investigate if 40s-50s, common/normal

Question 20

physiology / signs of fertility decline

Answer 20

• age 35, rapid after 37
• increased SA, chromosomal abnormalities
• day 3 FSH measure egg cohort
• AMH declines
• decreased antral follicle cou t

Question 21

vaginal symptoms of menopause

Answer 21

• dry, itch, odour, duspareunia, pain
• tissues fragile, bleeding
• pallor, dry, loss of rugae

Question 22

physiology of genitourinary syndrome of menopause

Answer 22

• worsens /w age
• thinner epithelium
• more infection from vag + rectal bacteria, lactobacilli decline
• pH rises
• vag lubrication decreased
• less blood flow, elastin, collagen

Question 23

urinary symptoms of aging (not correlated /w menopause)

Answer 23

stress, urgency, fre, dysuria, nocturia, incontinence

recurrent UTI - anatomic causes + less E

Question 24

RFs for urinary symptoms

Answer 24

obese
DM
parous
depression
hysterectomy
family hx

Question 25

sleep disorders in aging

Answer 25

apnea RLS meds - SSRIs depression/anxiety hot flashes - trigger awakening early in night, later in night awakening triggers hot flash

Question 26

sleep disorder lined to

Answer 26

``` chronic illness fibromylagia heart disease mood disorders work injury ```

Question 27

tx of sleep issues

Answer 27

sleep hygiene CBT yoga, acupuncture estrogen may help meds

Question 28

tx mood disorders in menopause

Answer 28

psychiatry SSRIs, estrogen may help in addition but not primary

Question 29

osteoporosis definition

Answer 29

BMD > 2.5 standard deviations below curve for young adult women or fragility fracture

Question 30

RFs for osteoporosis

Answer 30

``` age hx fractures fam hx x-ray shows osteopenia smoking low BMI meds: anti-epileptics, steroids, hormone suppressives, heparin, immunosuppressives, chemo hyperthyroidism alcoholism malabsorption ```

Question 31

prevention of osteoporosis

Answer 31

1000 IU vitamin D for all menopausal women Ca 1250 mg/day by diet or supplement

Question 32

loss of estrogen effect on bones

Answer 32

loss inhibition of bone resorption

Question 33

risk of early menopause

Answer 33

MI + CHF increased 2-3x if not replaced until age 51

Question 34

cardiovasc changes in menopause

Answer 34

- LDL rises - vasc changes due to lost E + P - coagulation: fibrinolytic and pro-coagulation factors increase - more vasoconstriction - nitric oxide increases, ACE decreases - insulin resistance increases

Question 35

causes of sexual dysfunction in menopause

Answer 35

- social, psychologic - partner loss, illness, body image, sleep - vag atrophy - testosterone decreased

Question 36

tx of sex dysfunction

Answer 36

- flibanserin being approved - SSRI to improve desire | - low dose transdermal testosterone - off label, may try if BSO

Question 37

estrogen + dementia

Answer 37

- connection controversial - some studies say protective, some say causes cog decline - memory change in menopause common

Question 38

exercise in menopause

Answer 38

strength/ resistance aerobic flexibility/stretch balance

Question 39

benefits of exercise

Answer 39

``` sleep mood pain osteoporosis falls risk BC risk CVD DM ```

Question 40

Tx for vasomotor symptoms

Answer 40

- CAM: black cohosh + vit E = minimal benefit, soy maybe, hypnosis - CBT - avoid alcohol + smoking - HRT - SSRI + SNRI: venlafazine, paroxetine (not if on tamoxifen), fluoxetine, escitalopram (SE: nausea, headache, sexual dysfunction) - eszopiclone for night time - clonidine - gabapentin - causes drowsiness, good for night sweats

Question 41

tx for vaginal dryness

Answer 41

lubricants for sex moisturizers - replens hyaluronic acid products local estrogen

Question 42

bone health management

Answer 42

ca vit d exercise/fall prevention BMD after 65 or if RFs meds for osteoporosis - HRT if younger - bisphosphnates - SERMs - raloxifene (spinal #) - RANK ligand inhib - PTH hormone if severe

Question 43

options for HRT

Answer 43

- estrogen, add P if uterus for endo protection - conjugated equine estrogen (premarin), multiple estrogens - oral estradiol - estradiol in gel or patch - local: ring, vag tablets (vagfm), cream - progestin: daily - amenorrhea, 10-14 days a month to minimize dose - may menstruate - oral progesterone, medroxyprogesterone, norethindrone acetate oral, progestin, IUD - or use TSEC: tissue selective estrogen complex, equine estrogens + SERM so no prog needed (no effect on uterus) - combo therapies: patch, pills - nonsmoking + menstruating perimenopausal can use OCP until age 54 (good cycle control but more E so higher thrombolic risk) - progestins alone may help hot flashes

Question 44

indications for HRT

Answer 44

- vasomotor symptoms - vaginal atrophy (try local first) - 2nd line: osteoporosis preention in symptomatic women or alts causing side effects

Question 45

risks of HRT

Answer 45

- stroke- rare, more if older - DVT + PE (oral, 60+, and higher doses) - BC in some formulas after 5 years, higher longer used, similar risk as delay childbirth until > 30 or being 20% overweight - gall bladder disease risk - risk med interventions b/c of bleeding - ? CHD if E + P

Question 46

benefits of HRT

Answer 46

- tx of hot flash: reason to rx - mood improvement - vag symptoms - osteoporisis prevention - ? sleep - ? colorectal cancer - not recommended to use FOR CVD, but estrogen alone may benefit in younger

Question 47

duration of HRT

Answer 47

- start within 5 years of menopause - tx as long as necessary, re-evaulated periodically, long term may be used if understand the risks - benefits > risks usually if under 60 or within 10 years of menopause - use local estrogen if vag symptoms only

Question 48

CI to HRT

Answer 48

``` hx BC or estrogen dep uterine Ca pregnancy CAD/CHF, MI or stroke hx of VTE or TIA active liver disease unexplained vg bleed or high risk endo Ca ```